Cytomegalovirus ischemic colitis: a near-fatal presentation of HIV infection

Cytomegalovirus infection occurs in immunocompromised patients. We present a 45-year-old male with no prior medical history who presented to the hospital with weight loss and non-bloody diarrhea. During hospitalization, he developed severe hematochezia and hypotension. Colonoscopy revealed dusky, friable mucosa. The patient arrested and was resuscitated. Specimen from emergent colectomy showed ischemic changes secondary to cytomegalovirus infection of endothelium and small-vessel thrombosis. An HIV test was subsequently positive with CD4 count of 2 per microliter. The patient was treated with antiretroviral therapy and ganciclovir. He survived postoperative infections and was eventually discharged. In summary, this case of near-fatal cytomegalovirus colitis represents an unusual presentation of undiagnosed HIV infection. Cytomegalovirus infection should be included in the differential diagnosis of immunocompromised patients with gastrointestinal symptoms. Hematochezia may be from intestinal ulceration or severe ischemic damage. Antiretroviral therapy and ganciclovir or foscarnet should be initiated promptly. Surgery is indicated in life-threatening hemorrhage or obvious bowel necrosis.     

Human intestinal spirochetosis in an immunocompromised host: evaluation of eradication therapy by endoscopy, histopathology and bacteriology

Human intestinal spirochetosis (HIS) is a colorectal infectious disease caused by Brachyspira species. We describe HIS in an immunocompromised, 62-year-old Japanese man who presented at Jichi Medical University Hospital with symptoms of diarrhea and bloody stool. He had rheumatoid arthritis that had been treated with immunosuppressive drugs for 10?years. Colonoscopy revealed multiple erythematous spots in the cecum and colon. A histopathological examination identified intestinal colonization by spirochetes, and Brachyspira pilosicoli was isolated from biopsy specimens, indicating a diagnosis of HIS. Metronidazole eradicated the spirochetes, the intestinal mucosa recovered to normal, and the clinical symptoms disappeared. This case suggests that it is important to keep in mind HIS in the differential diagnosis of immunocompromised patients with chronic diarrhea and bloody stool.     

Rituximab-induced Ileocolitis in a Patient with Gastric MALToma: A Case Report and Literature Review

Rituximab (RTX) is effective for treating cancer, but reports of RTX-associated enterocolitis are limited. We herein report the case of a 65-year-old man who developed RTX-induced ileocolitis. He was diagnosed with gastric mucosa-associated lymphoid tissue lymphoma (MALToma) and treated with RTX. He complained of bloody diarrhea after RTX. Mucosal inflammation on colonoscopy indicated RTX-induced ileocolitis. He was treated with corticosteroids, and his symptoms improved. We reviewed the RTX-associated gastrointestinal adverse events and classified the features into ulcerative colitis, Crohn''s disease, microscopic colitis, and ileocolitis. To our knowledge, this is the first case of a Japanese patient who developed RTX-induced ileocolitis.     

Ischemic colitis after capecitabine plus cisplatin treatment in advanced gastric cancer

Systemic chemotherapy can be complicated by colonic toxicity, which usually determines the onset of pseudomembranous colitis and, rarely, of ischemic colitis in patients with cancer. This report describes the case of a 45-year-old man with advanced gastric cancer who developed severe ischemic colitis after chemotherapy with cisplatin and capecitabine. The patient developed symptoms of gastrointestinal toxicity with abdominal pain and bloody diarrhea. He had a normal white blood cell count throughout his illness; the assay of stool specimens for Clostridium difficile toxins and the stool cultures were both negative. An endoscopy showed a mild, transient ischemic colitis. Although cisplatin is related to severe colonic cytotoxicity, it has not been previously reported that capecitabine induces arterial thrombosis and necrosis of the gastrointestinal mucosa and inhibits angiogenesis. Pseudomembranous colitis is the most frequent complication in patients with cancer who undergo capecitabine-based chemotherapy and develop gastrointestinal toxicity. Once Clostridium difficile infection has been excluded, a diagnosis of ischemic colitis should be considered, especially in patients with cancer who have normal white blood cell counts.     

Cytomegalovirus enteritis after autologous peripheral blood stem cell transplantation

A 61-year-old male with non-Hodgkin's lymphoma (peripheral T-cell lymphoma, unspecified, clinical stage IVb) received autologous peripheral blood stem cell transplantation (PBSCT) during first remission. He was seropositive for cytomegalovirus (CMV) prior to autologous PBSCT. His posttransplant clinical course was complicated by refractory CMV enteritis, which manifested persistent abdominal pain, diarrhea, and bloody stool. Generally, gastrointestinal CMV disease is relatively rare after autologous PBSCT. However, our case indicates that CMV infection must be considered as a differential diagnosis in cases of unexplained hemorrhagic enteritis following autologous PBSCT.     

Small intestinal perforation caused by cytomegalovirus reactivation after subtotal colectomy for ulcerative colitis: report of a case

A 79-year-old woman with bloody diarrhea was diagnosed with ulcerative colitis. She developed intestinal perforation after high-dose steroid therapy. An emergency laparotomy revealed a perforation in the ascending colon, and a subtotal colectomy was performed with an ileostomy and a mucous fistula in the sigmoid colon. Histological findings of the resected colon showed the presence of cytomegalovirus in the endothelial cells of vessels around the ulcer floor. Twelve days after the laparotomy, she developed an ileal perforation with a bloody discharge from the ileostomy and underwent an emergency laparotomy. Multiple intestinal perforations were found in the ileum, and the perforated ileum was resected. Cytomegalovirus infection was controlled with ganciclovir postoperatively. Histological findings of the resected ileum showed the presence of cytomegalovirus in the endothelial cells of vessels around the ulcer floor. This is the first report of ileal perforation due to cytomegalovirus infection confirmed pathologically in a patient with ulcerative colitis.     

Cytomegalovirus infection in a patient with Crohn's ileocolitis.

Cytomegaloviral enterocolitis is an uncommon infection that can complicate inflammatory bowel disease. A case of a patient with a three-year history of Crohn's disease is reported. He had been in a stable condition on mesalamine 4 g/day and methylprednisolone 10 mg/day for three years until four weeks before admission. The patient was admitted with complaints of fever, abdominal pain and watery diarrhea. A diagnosis of an exacerbation of Crohn's disease was established. The radiological examination revealed narrowing of the terminal ileum. Multiple fistulas and abscess-like images were observed. The patient then underwent ileocolic resection and ileostomy. The histopathological examination revealed Crohn's ileocolitis with superimposed cytomegalovirus infection. In patients with rapidly deteriorating inflammatory bowel disease, cytomegalovirus infection should be kept in mind as one of the differential diagnoses.     

Gastrointestinal cytomegalovirus disease secondary to measles in an immunocompetent infant: A case report

BACKGROUNDGastrointestinal cytomegalovirus (CMV) disease occurs commonly in immunocompromised/immunodeficient patients with advanced human immunodeficiency virus infection, neoplasm, solid organ transplantation, hematopoietic stem cell transplantation, or treatment with immunosuppressants, but is rarely reported in association with measles infection.CASE SUMMARYWe describe a case of extensive gastrointestinal CMV disease secondary to measles infection in a 9-mo-old boy who presented with persistent fever and bloody diarrhea. His condition was improved after ganciclovir treatment. Serological analysis of CMV showed negative immunoglobulin (Ig) M and positive IgG. Blood CMV-DNA was 9.26 × 10³ copies/mL. The diagnosis of gastrointestinal CMV disease was confirmed by histopathological findings of intranuclear and intracytoplasmic inclusions and Owl’s eye inclusion. This case highlights the differential diagnosis and histopathological characteristics of gastrointestinal CMV infection and laboratory tests.CONCLUSIONExtensive gastrointestinal CMV lesions can be induced by the immune suppression secondary to measles infection. Rational, fast, and effective laboratory examinations are essential for suspected patients.     

Potential mechanisms and significance of acute pancreatitis-associated liver injury

Reports of cytomegalovirus (CMV) colitis mainly concern patients with immunocompromisation resulting from, among others, HIV infection, allogeneic bone marrow transplantation and solid organ transplantation. CMV colitis rarely occurs during standard chemotherapy for non-Hodgkin's lymphoma (NHL). An unusual case of CMV enterocolitis in a 62-year-old patient is reported. After a first course of salvage chemotherapy for NHL, diffuse erosions and sloughing mucosa were seen throughout the large bowel. The final diagnosis was based on histological findings. Although ganciclovir and foscarnet are effective for CMV viremia, their use in the treatment of severe diarrhea in our patient did not result in improvement for one week, whereas concomitant use of octreotide led to rapid improvement. Octreotide may therefore be an effective agent for severe colitis.     

Two siblings with allergic purpura following Salmonella O9 enterocolitis

Two siblings with allergic purpura after Salmonella O9 infection were reported. A girl (patient 1) aged 4 years and 4 months started to have knee joint pain and abdominal pain followed by purpura of the lower extremities and was referred to us for treatment of allergic purpura. She had contracted enterocolitis one month before visiting our hospital and Salmonella enteritidis was identified. During the course of the illness she had nephritis associated with allergic purpura. However, she made a favorable progress and proteinuria and hematuria disappeared within 6 months. A boy (an elder brother of patient 1) aged 6 years was admitted to our hospital because of the allergic purpura. He similarly had contracted Salmonella enterocolitis. He had severe gastro-intestinal symptoms including abdominal pain, vomiting and bloody stool, which rapidly subsided after initiation of treatment with intravenous hyperalimentation combined with prednisolone. It is possible that allergic purpura in our patients was closely associated with Salmonella enteritidis infection. Further accumulation of cases is a requisite to clarify an association of Salmonella enteritidis infection with allergic purpura and pathogenesis of allergic purpura.     

Severe cytomegalovirus enterocolitis after standard chemotherapy for non-Hodgkin's lymphoma

Reports of cytomegalovirus (CMV) colitis mainly concern patients with immunocompromisation resulting from, among others, HIV infection, allogeneic bone marrow transplantation and solid organ transplantation. CMV colitis rarely occurs during standard chemotherapy for non-Hodgkin's lymphoma (NHL). An unusual case of CMV enterocolitis in a 62-year-old patient is reported. After a first course of salvage chemotherapy for NHL, diffuse erosions and sloughing mucosa were seen throughout the large bowel. The final diagnosis was based on histological findings. Although ganciclovir and foscarnet are effective for CMV viremia, their use in the treatment of severe diarrhea in our patient did not result in improvement for one week, whereas concomitant use of octreotide led to rapid improvement. Octreotide may therefore be an effective agent for severe colitis.     

Rapidly progressed secondary amyloidosis in a patient with Still's disease with gamma-allele in his SAA 1 gene]

A fifteen-year-old boy was admitted to our hospital because of lower abdominal pain, watery diarrhea and mucobloody stool. Two years before admission, he was diagnosed to have Still's disease presenting with polyarthritis, sore throat, remittent fever and typical skin rash. He had been treated with non-steroidal anti-inflammatory agents, oral prednisolone and low-dose methotrexate. Although he was almost free of symptoms during the next two years, serum C-reactive protein (CRP) levels continued to be elevated moderately. He began to complain of lower abdominal pain and loose stool in May 1997 and came down with mucous-bloody diarrhea in June. Laboratory data on admission showed an elevated level of serum CRP (13.9 mg/dl). The biopsy of the stomach, ileum, sigmoid colon and rectum revealed the deposition of amyloid protein of AA type, which confirmed the diagnosis of secondary amyloidosis. The dose of prednisolone was increased and dimethyl sulfoxide per os or rectum was instituted, which improved his gastro-intestinal symptoms to some extent. However, fever, arthritis and diarrhea recurred along with tapered prednisolone dosage. In addition to gastro-intestinal symptoms, arrhythmia and proteinuria appeared. These symptoms were considered to reflect general deposition of amyloid in his body. He is now on immunosuppressive agent and high-dose prednisolone. Several studies report the higher frequency of gamma-allele of SAA 1 gene in the cases of rheumatoid arthritis with AA-amyloidosis than in those without. In the patient presented here, molecular biological analysis revealed that his SAA 1 gene was composed of beta- and gamma-allele. The presence of gamma-allele in his SAA 1 gene might be one of the factors that predisposed him for generalized deposition of amyloid protein in such a short period of time.     

Endoscopic Findings of Acute Intestinal Graft-versus-host Disease after Bone Marrow Transplantation

Abstract: To clarify the endoscopic findings of intestinal graft-versus-host disease (GVHD), we reviewed the endoscopic findings of 19 patients who underwent colonoscopy because of abdominal pain, watery diarrhea or bloody stool among 196 bone marrow transplant (BMT) recipients between 1986 and 1997. BMT had been performed for treatment of various hematopoietic disorders. Eleven patients were diagnosed as having intestinal GVHD, based on the pathological findings of biopsy specimens. Although the grade of inflammation differed among cases, the terminal ileum was most vulnerable to GVHD, based on our observations. Compared to the ileum, findings in the colon tended to be mild. Therefore, evaluation of intestinal GVHD requires observation of the terminal ileum when the colorectal findings are mild. The findings consisted of shallow ulcerations, erythema and easy bleeding. However, there were very few specific endoscopic findings of intestinal GVHD. Since intestinal GVHD and cytomegalovirus (CMV) enterocolitis share several clinical characteristics, including preferential involvement of the ileum, biopsy is indispensable for the final diagnosis.     

Abdominal miliary tuberculosis in a patient with AIDS: a case report

We present a 34 year old patient, intravenous drug user, hospitalized with fever, distortion of general status, dry irritating cough, abdominal colicative pains, and we established the diagnosis of HIV infection advanced stage/AIDS; his antecedents revealed (August 2000) abdominal tuberculosis not treated during the last 3 months. He presented a pneumonia with Pneumocystis carinii during hospitalization. Death was due to a colon perforation with secundary peritonitis. Miliary tuberculous lesions in liver, spleen and colon were revealed at necropsy and cytomegalovirus was identified in necrotic samples also.     

Severe digestive complications of AIDS in a group of patients from Zaire

Severe digestive complications of acquired immune deficiency syndrome (AIDS) were observed in 9 patients among a group of 17 patients from Zaire treated for AIDS in Belgium between May 1979-April 1983. Among the 9 cases, there were 10 ailments of the upper digestive tract, 7 of intestinal disorders, 3 of hepatic disorders, and 2 of pancreatic disorders. The average age of affected patients was 35 years. 4 men averaged 32 years and 5 women averaged 39 years. Their average stay in Belgium was 8 months. All 9 were anorexic and had lost at least 10 kg over the past year. 6 were pyretic and developed palpable adenopathies. 7 patients had episodic or continuous diarrhea in the early stages of illness and 8 had diarrhea in the later phase. 1 patient had bloody diarrhea. None were homosexual or drug addicted or had histories of transfusions. None was dysphagic. The patients exhibited lymphopenia affecting primarily the helper T lymphocytes. 7 patients had Candida albicans infections of upper digestive tract. 1 patient had an esophageal herpes infection. 4 patients had enterocolitis caused by opportunistic organisms: Cryptosporidium, Isospora Belli, cytomegalovirus, Clostridium Difficile, or Salmonella. 2 patients had septicemia caused by Salmonella and 1 had septicemia caused by Shigella. All 9 patients had at least 1 of the markers of hepatitis B. By April 1984, 8 patients had died and 1 who returned to Zaire had been lost to follow-up. The cause of death of the 3 patients for whom it was known was generally a nondigestive complication. Analysis of stool samples was found to be most useful means of diagnosing digestive complications of AIDS. Systemic infection with cytomegalovirus is very frequent in AIDS. The case in this series was diagnosed after discovery of inclusions in the intestinal mucus after repeated noncontributory analyses of the stools. In cases of enterocolitis, the endoscopic appearance of the mucus is not very specific and colposcopy is less useful than of stool samples. Upper endoscopy is very useful in diagnosis of Candida, which responds well to treatment. Hepatic biopsy and laparoscopy appear to be of limited usefulness, since liver and pancreatic involvement are usually self-limited with slight clinical manifestations. Endoscopic examinations pose the problem of possible contaminatin. The endoscope and all accessories should be systematically disinfected before and after use.     

Ganciclovir treatment of cytomegalovirus infection of the gastrointestinal tract after marrow transplantation

Ganciclovir, an acyclic nucleoside with improved activity against cytomegalovirus in vitro, was used to treat 15 marrow transplant patients with symptomatic cytomegalovirus infection of the gastrointestinal tract. Eleven of the 15 had improvement in one or more of their clinical signs or symptoms during treatment. No clinical relapses were observed. Viral excretion from throat, urine and blood stopped at a median of 6 days of treatment, but six patients had recurrence of viral excretion 7-25 days after treatment was stopped. The only toxicity was the development of reversible neutropenia in eight of 15 patients after 10-19 days of treatment. Neutropenia was not related to duration of treatment, plasma drug levels or to the neutrophil count at the beginning of treatment. Although treatment with ganciclovir may be associated with marrow suppression, the serious nature of gastrointestinal infection due to cytomegalovirus in the immunocompromised host, the antiviral effect and the possible clinical improvement observed in vivo, and the lack of other effective treatments justify further controlled studies with this agent in immunocompromised patients with serious cytomegalovirus infection.     

Successful treatment of Good syndrome with cytomegalovirus duodenoenteritis using a combination of ganciclovir and immunoglobulin with high anti-cytomegalovirus antibody titer

We describe the case of a 64-year-old woman with Good syndrome who presented with watery diarrhea and abdominal distention caused by cytomegalovirus (CMV) duodenoenteritis. Thymoma and hypogammaglobulinemia were first identified when the patient was 58 years old. She had repeatedly complained of symptoms even after thymectomy. Abdominal radiography revealed multiple air-fluid levels, and computed tomography revealed ascites and dilation of the small intestine. Immunofluorescent staining of specimens obtained by duodenal mucosal biopsy revealed intracellular inclusion bodies of CMV, although serum CMV pp65 antigenemia assays yielded negative results. CMV infection of the small intestine caused mucosal edema resulting in malabsorption. The patient was treated using ganciclovir and an immunoglobulin preparation with a high titer of antibodies against CMV (CMV-Ig), and subsequently made a rapid recovery from abdominal symptoms. When patients with Good syndrome complain of abdominal symptoms, particularly chronic diarrhea, a diagnosis of CMV gastroenteritis should not be excluded, even if negative results are obtained for CMV pp65 antigenemia assays. Combination therapy of ganciclovir and CMV-Ig seems useful for patients with CMV gastroenteritis.     

Life-threatening hemorrhage due to cytomegalovirus infection of the gastrointestinal tract

Cytomegalovirus infection of the gastrointestinal tract of normal hosts is very rare. On the other hand, this is a common cause of morbidity in immunocompromised hosts. Herein we describe the case of a 52-year-old male who underwent a gastrectomy due to a severe gastrointestinal hemorrhage. Histological examination showed the characteristic cytomegalovirus inclusion bodies. The diagnosis was confirmed with immunohistochemistry and his immune system revealed no abnormality. We believe that, although it is very rare, cytomegalovirus infection should be kept in mind for non-immunocompromised patients with upper gastrointestinal bleeding or multiple gastric ulcers.     

Post-colonoscopic Listeria septicemia in ulcerative colitis during immunosuppressive therapy

A 78-year-old man who had been diagnosed with ulcerative colitis was admitted because of uncontrolled severe, frequent, bloody diarrhea. He was treated with immunosuppressive therapy that included corticosteroid and azathioprine. Colonoscopy was used to assess disease activity. This revealed that the mucosa of his digestive tract from the rectum to the ileum was damaged. He developed a high-grade fever soon after colonoscopy. Blood culture demonstrated Listeria monocytogenes. Treatment was changed to intravenous ampicillin for 20 days. His general body symptoms, including the bloody diarrhea, improved after treatment. We assume that the colonoscopy induced Listeria monocytogenes septicemia through bacterial translocation in this patient.     

A patient who survived total colonic ulcerative colitis surinfected by cytomegalovirus complicated by toxic megacolon and disseminated intravascular coagulation

The authors report the case of a patient aged 60-year-old who survived ulcerative colitis complicated by toxic megacolon and disseminated intravascular coagulation. This patient was not known for this ulcerative colitis and was first hospitalised for a suspicion of diverticulitis. The admission symptoms were fever, abdominal pain and bloody diarrhoea. The evolution was defavorable under antibiotics and sulfasalazine. The patient was readmitted 5 days after he left hospital, and the diagnosis of UC was based on colon biopsy made during the first hospitalisation. A treatment with methylprednisolone was started and the patient worsened day by day with apparition of toxic megacolon and disseminated intravascular coagulation. Subtotal colectomy was performed for degradation of general status and coagulation factors. Pathological findings confirmed ulcerative colitis with toxic megacolon. Cytomegalovirus inclusions were demonstrated on the colonic specimen and confirmed by PCR. In this report the authors discuss the etiology of toxic megacolon and disseminated intravascular coagulation in ulcerative colitis surinfected by cytomegalovirus. Mortality of these pathologies is high necessitating rapid diagnosis of cytomegalovirus infection by sigmoid biopsy. Management requires immunosupression interruption and ganciclovir therapy, or surgery in unsuccessful medical treatment.